WORKING AND LEARNING IN THE SERVICE Managing continuing professional development Professor Janet Grant Centre for Medical Education in Context [CenMEDIC] Open University University College London Medical School United Kingdom

WHAT IS CPD? Continuous……… Basic medical education Postgraduate (specialty) training Continuing professional development Continuing professional development (Europe) Continuing medical education (USA) Maintenance of competence (North America) Continuous………

CONTINUING PROFESSIONAL DEVELOPMENT For patient safety and ethics For cost-effectiveness For regulation and licensing of the profession For improvement of the healthcare service For personal and professional development and satisfaction To meet international standards All should contribute to improvement of the service

HOW CAN WE MAKE CPD DELIVER THESE BENEFITS? Collection of credits for activity is the most common system

IS COLLECTING CPD CREDITS EFFECTIVE? No rationale for award of credit No systemic relationship to need No evidence of effect on practice Doctors can participate just for ease or the meal….. Not, not really BUT… Offers opportunities for CPD Indicates that CPD is important Good for the bureaucracy

THE CENTRAL PROBLEMS: Collecting credits is an isolated process, not systematically linked with personal or service need Credit recognition systems do not recognise actual effective ways of learning at senior level Learning is a process, not an event Credits can be offered for an effective learning process HOW!?

THE EVIDENCE IS POOR QUALITY They frequently fail to use control groups or randomisation Statistical analysis of data is often inadequate Issues of validity are frequently ignored Many studies are correlational and/or retrospective (and are thus unhelpful in terms of increasing the understanding of causal processes) Fail to isolate the influences of particular activities from those of intervening variables Inadequate measurement of outcomes

RESEARCH DESIGN IS DIFFICULT Too many uncontrolled, intervening, unmeasurable variables Learners CPD activity Changes in learners Changes in professional practice Changes in the outcomes of practice

An effective CPD process has: WHAT DO WE KNOW? An effective CPD process has: A stated reason for the CPD to be done An identified learning method Some follow-up AND>>>>>

Much actual CPD is not credit bearing Individual doctors vary considerably in their preference for different learning methods Much actual CPD is not credit bearing Changes to practice are more satisfying if they have arisen from personal incentive rather than from external pressures CPD does make a difference, but programme planners must pay attention to the circumstances under which it does CPD must be relevant to the individual in their own context Prevalence of self-directed learning

SO HOW CAN CPD BE…… Transparent and accountable? Regulated? Relevant to the health care service? Relevant to the interests of the individual clinician? By using credits that recognise the process of learning rather than isolated events Cost effective? Based on effective learning methods?

European Association of Senior Hospital Physicians Dr Thomas Zilling, Foreword by

A SIMPLE 4-STEP PROCESS will be learned? WHAT will it be learned? HOW the learning to reinforce and apply it USE

How do senior doctors learn? BUT FIRST……… How do senior doctors learn? Research and experience tell us….

The process of professional education depends on immersion in practice SITUATED LEARNING The process of professional education depends on immersion in practice It is from immersion in practice that effective CPD arises Depth of immersion increases with each successive stage of education and practice. At the level of CPD, it is total.

THIS DOCTOR LEARNS IN HIS OWN WAY…….. There is no best method of learning. There is no widely shared preference. How people like to learn depends on context, culture and purpose. That is a challenge for credit-based systems that set different values on different ways of learning.

IS CPD AN ISOLATED EVENT? CPD is an integral part of a doctor’s professional life – it is not a separate stream THE CHALLENGE: To support doctors’ own ways of learning, not to force them into different ways just because they are measurable and observable

FACILITATING EFFECTIVE LEARNING Doctors learn effectively in many ways already There is no ‘best’ learning method: people vary Effective learning can be: specifically needs related for the doctor’s general professional development So there must be a large element of personal professional choice Just linking CPD to known needs will not: promote development of the individual or the profession. prepare for the future CPD cannot be used instrumentally.

SO WHAT WILL BE LEARNED IN THIS INDIVIDUAL WAY? Although sometimes there will be a need to teach health care professionals about a developing condition e.g. HIV, swine ‘flu……………. In general,……..

THERE IS NO CPD CURRICULUM And there should not be one that is pre-specified It must arise from the practice and judgment of doctors and from emerging health service needs.

ENSURE THAT LEARNING IS RELATED TO PRACTICE Doctors are unlikely to share many common learning needs: CPD needs arise from practice and judgment To find ways of supporting individual doctors to identify learning needs arising from practice and feed that back into their practice THE CHALLENGE:

DO WE NEED TO TEACH DOCTORS THE SKILLS OF EFFECTIVE LEARNING DO WE NEED TO TEACH DOCTORS THE SKILLS OF EFFECTIVE LEARNING? The Good CPD Guide Can they identify their learning needs? 48 methods of learning needs assessment Do they meet the needs of the health care service? Planning CPD in relation to the development of the service Do they continue to learn? 40 methods of learning Do they show effectiveness & reinforce learning in practice? 41 ways of showing effectiveness and reinforcing learning

ALL WE NEED TO DO IS…… Build all this into a managed system for CPD

A SIMPLE 4-STEP PROCESS will be learned? WHAT will it be learned? HOW the learning and show effects USE

STEP METHOD EFFECT 1. IDENTIFY WHAT TO LEARN Reflection Peer appraisal Context factors [service needs] QA processes Ensures that intended learning derives from: personal need, professional developments, needs of the health service

THE UK APPRAISAL PROCESS Peer review of doctor’s performance Personal reflection Consider doctor in the local healthcare service Set out development needs Agree learning plan Seek support for the learning Part of revalidation / relicensure

A rational and transparent record is created STEP METHOD EFFECT 2. PLAN HOW TO LEARN Personal development plan, or other record A rational and transparent record is created

PERSONAL DEVELOPMENT PLAN An action plan, based on awareness, reflection, goal-setting and planning learning for personal development in the context of a career, the job, education, or self-improvement So you have a record for accountability and bureaucracy

Learning is personally effective STEP METHOD EFFECT 3. LEARN In any way that is appropriate to the need, the person, and the context Learning is personally effective

EFFECTIVE PROFESSIONAL LEARNING METHODS Academic activities Meetings Learning from colleagues Learning from practice Technology-based learning and media Management and quality processes Specially arranged educational events No rational reason for assigning a credit value to any of these – all are valid

4. USE THE LEARNING AND SHOW EFFECTS STEP METHOD EFFECT 4. USE THE LEARNING AND SHOW EFFECTS Dissemination to others Incorporation into practice Further learning Learning is carried back to the workplace and service

TAKING LEARNING BACK TO THE WORKPLACE Reviewing practice Teaching others Changing practice Confirming current practice This will improve the healthcare service!

MANAGED CPD IN PRACTICE… You no longer need to count CPD hours. Instead: Reflect on your practice and identify your learning and development needs Plan how to address your needs and knowledge gaps Record and evaluate your activities, using downloadable templates http://www.sra.org.uk/solicitors/cpd/tool-kit/continuing-competence-toolkit.page

THE PROCESS Information How to reflect How to plan How to address learning needs How to record and evaluate

TEMPLATES

DECLARATION Appraisal or peer conversation Annual Declaration: I have reflected on my practice and addressed any identified learning and development needs Regulatory monitoring

CAN THE QUALITY OF CPD BE MEASURED BY OUTCOMES? NO because Too many intervening and uncontrollable variables between learning and patient outcomes The conditions of practice sometimes stop new learning being used Doctors must acquire new knowledge that may not be predictably used e.g. If patients do not require it Not all CPD should be instrumental. Some must be for general professional updating.

The key to effective CPD is in how the process is managed: WHAT? HOW ? LEARN USE

MANAGED CPD CAN IMPROVE THE HEALTHCARE SERVICE BY: Deriving from health service needs Being tailored to the individual doctor's needs and practice Assuring return to practice Allowing a personal learning plan that suits the individual Transparent and monitorable Allowing targeted CPD when healthcare service development requires that

FORMAL RECOGNITION OF THIS PROCESS IS REQUIRED For credit or certification

For transparency and accountability Process Documentation Certification For the profession For the doctor For the service For regulation For transparency and accountability

To help the profession to do better what it does well already. will be learned? WHAT will it be learned? HOW LEARN the learning and show effects USE To help the profession to do better what it does well already.